rheum Flashcards
wtf is osteoarthritis ? + RF
‘wear and tear’ in synovial joints (not inflam like rheum), result of genetics, overuse and family history
- imbalance between worn down cartilage and chondrocytes repairing it = structural issues in joint. abnormalities can be seen on x-ray
RF: obesity, age, occupation, trauma, female, family history
osteoarthritis - key x-ray changes? (mnemonic)
Loss of joint space Osteophytes (bony lumps growing on bones of spine/joints) Subchondral sclerosis (increased density of bone along joint line) Subchondral cysts (fluid-filled holes in bone - geodes)
significant changes could be found in people who do not show symptoms or vice verse
presentation of osteoarthritis and commonly affected joints? + 5 general signs in hands
joint pain and stiffness - worsened by activity (this is opposite in rheumatoid)
deformity, instability, reduced function in joint
commonly affected joints: hips, knees, sacro-iliac joints (pelvis), wrists, cervical spine, proximal & distal-interphalangeal joints in hands (PIPs & DIPs), carpometacarpal joint at base of thumb (CMC) - this is a saddle joint: metacarpal bone sat on trapezius used a lot in everyday activity hence wear and tear
hands:
- Heberden’s nodes (DIP joints)
- Bouchard’s nodes (PIP joints)
- squaring at base or thumb at CMC joint
- weak grip
- reduced range of motion
diagnosis and management of osteoarthritis ?
can be diagnosed without investigation if patient over 45, has typical activity related pain and has no morning stiffness/sturdiness lasting less than 30 mins
manage:
- patient education about lifestyle changes eg. weight loss, physiotherapy, occupational therapy, orthotics (eg. shoe supports)
- stepwise use of analgesia=
1. oral paracetamol and topical NSAIDs/capsaicin (chilli pepper)
2. oral NSAIDs and PPI to protect stomach eg. omeprazole - better intermittently than continuously
3. opiates eg. codeine, morphine - cautiously as significant side effects, dependence, withdrawal - hence don’t work for chronic pain
intra-articular steroid injections = temporary reduction in inflam and improve symptoms
joint replacement = in severe cases eg. hip and knee
wtf is rheumatoid arthritis ?
autoimmune, causes chronic systemic inflammation of synovial lining of joints (synovitis), tendon sheaths and bursa. usually symmetrical and affects multiple joints = symmetrical poly arthritis
inflam of tendons increases risk of tendon rupture
3x more likely in women, usually develops middle age but can present whenever, fam history increases risk
rheumatoid arthritis - genetic associations and antibodies ?
genetics:
HLA DR4 - often present in rheumatoid factor (RF) positive patients
HLA DR1 - occasionally present in rheumatoid arthritis patients
RF is autoantibody present in 70% patients which targets Fc portion (portion used to bind to cells of immune system) of IgG antibody = this causes activation of immune system against patients own IgG causing systemic inflam RF can be any class of immunoglobulin but is usually IgM (AKA RF is a type of antibody that attacks ANOTHER type of antibody within the body)
osteoarthritis vs rheumatoid arthritis:
age of onset, pattern of joint involvement, most common joints affected, joint stiffness, effect of movement, systemic symptoms?
Age of onset: 45+ / 20-40
Pattern of joint involvement: Asymmetrical / Symmetrical
Most common joints affected: DIPJs, Hips, Knees / PIPJs, Wrists and feet , (DIPJs rarely affected)
Joint stiffness: Transient joint stiffness for less than 30 mins / Early morning stiffness for more than 30 mins
Effect of movement: Pain worsens with movement / Pain eases with movement
Systemic symptoms: None / Yes - fatigue and malaise
extra-articular manifestations of rheumatoid arthritis?
Subcutaneous nodules
Pulmonary fibrosis with pulmonary nodules - Caplan’s syndrome
Felty’s syndrome - RA + splenomegaly + neutropenia
Anaemia of chronic disease
Episcleritis and scleritis
Carpal tunnel syndrome
diagnose rheumatoid arthritis if…? (5 S’s)
Slowly progressive Symmetrical Swollen Stiff Systemic symptoms (PAIN)
What would bloods show in rheumatoid arthritis?
FBC - normochromic normocytic anaemia
ESR/CRP - raised bc RA is inflam
RF - low specificity, raised in 80%
Anti-CCP - high specificity, raised in 30%, worse prognosis
rheumatoid arthritis - hand signs (4) and key x-ray changes? (mnemonic)
Boutonniere deformity of thumb
Ulnar deviation
Swan neck deformity
Z shaped deformity of thumb
Loss of joint space
Erosion
Soft tissue swelling
Soft bones
manage rheumatoid arthritis?
Non-medical - exercise / lose weight / physio
Pain management
NSAIDs / COX inhibitors (co-prescribed with PPIs)
Corticosteroids - during flare ups to suppress disease activity
Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Gold standard = methotrexate
Taken once a week
Folic acid taken alongside on a different day
Side effects = pulmonary fibrosis + teratogenic (halt pregnancy)
Biological Therapies
Anti-TNF - adalimumab / infliximab / etanercept
Anti-CD20 - rituximab
gout crystals vs pseudogout crystals?
gout = monosodium urate crystals
Needle shaped
strong Negative birefringence
yellow
Pseudogout = calcium pyrophosphate dihydrate crystals
rod/rhomboid shaped
weak Positive birefringence
blue
wtf is gout? + RF
Inflammatory arthritis associated with chronically high blood uric acid levels (crystal arthropathy)
urate crystals deposited in joint causing it to become hot, swollen, painful
60% occurs at 1st MTPJ of big toe
think of Henry VIII <3
male, obesity, high purine diet (red meat, shellfish, beer), alcohol, diuretics, existing cardio or kidney disease, family history
presentation of gout? precipitants of an attack?
Gouty tophi - subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears
DIP joints are most affected in the hands
typically presents with a single acute hot, swollen and painful joint (MTPJ of big toe, wrists, base of thumb/CMCJ)
Chronic polyarticular gout - rare except in pts with renal failure on long term diuretics
Precipitants- Aggressive intro / sudden cessation of hypouricaemic therapy Alcohol / shellfish binges Sepsis / MI / acute severe illness Trauma / surgery / dehydration
Diagnose/investigate gout?
Aspirated fluid will show to rule out septic arthritis
shows: no bacterial growth, MSU crystals (needle shaped, strong neg birefringent, yellow)
Joint xray shows: space between joint usually maintained, lytic lesions in bone, punched out erosions which may have sclerotic borders and overhanging edges
manage gout?
Acute attacks:
1st line - high dose NSAIDs
2nd line - colchicine - (common side effect = diarrhoea)
3rd line - corticosteroids
Prophylaxis:
Avoid purine rich foods
Reduce alcohol consumption
Lose weight
ALLOPURINOL = XANTHINE OXIDASE INHIBITOR
Less uric acid production = less monosodium crystals
NB - must not start until 1 month after acute attack. Once started can be taken through any following attacks
wtf is pseudogout?
crystal arthropathy, deposition of calcium pyrophosphate crystals on joint surface
Shedding of crystals into joint produces acute synovitis resembling acute gout
Typically affects large joints: knee / wrist / hip
(also known as chondrocalcinosis)
presentation of pseudogout?
older adult with a hot, swollen, stiff, painful knee. Other joints that are commonly affected are the shoulders, wrists and hips
can be chronic and affect multiple joints
can be asymptomatic (only seen on xray)
diagnosis/investigation for pseudogout?
exclude septic arthritis aspirate synovial fluid will show: No bacterial growth Calcium pyrophosphate crystals Rhomboid shaped crystals Positive birefringent of polarised light blue
xray:
Chondrocalcinosis - appears as a thin white line in middle of joint space (calcium deposition) - is diagnostic
other changes similar to osteoarthritis = LOSS
L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts
manage pseudogout?
Chronic asymptomatic changes found on xray don’t require action
Symptoms usually resolve on their own over a few weeks
Symptomatic Mx includes NSAIDs /
Colchicine / joint aspiration /
corticosteroids
Joint washout (arthrocentesis) is an option in severe cases
wtf is osteoporosis? + RF (mnemonic)
reduction in the density of the bones meaning less strong and more prone to fractures (osteopenia = less severe version)
RF: MY - personal history of fracture Steroid use Hyperthyroidism/hyperparathyroidism Alcohol/tobacco Thin (low BMI) - reduced skeletal loading Testosterone is low Early menopause Renal/liver disease Erosive/inflam bone disease eg. RA Dietary calcium low/malabsorption FAMILY - parental history of fracture
oestrogen is a protective factor hence postmenopausal women at higher risk due to lower O levels (unless on HRT)
investigate osteoporosis?
X-ray - demonstrates “fragility fractures”
DEXA scan:
- Gold standard
- Measures bone mineral density (BMD) at important fracture sites (hip reading is key)
- Generates Z scores (mean for their age) & T scores - compares BMD against a healthy 30 year old
hence: most clinically important outcome is the T score at the hip
Calculate FRAX score:
- Predicts the risk of a fragility fracture over the next 10 years
- usually first step
Bone density ranges:
> -1 = normal
-1 -> -2.5 = osteopenia
< -2.5 = osteoporosis
manage osteoporosis?
FRAX outcome without a BMD result will suggest one of three outcomes:
Low risk – reassure
Intermediate risk – offer DEXA scan and recalculate the risk with the results
High risk – offer treatment
FRAX outcome with a BMD result will suggest one of two outcomes:
Treat
Lifestyle advice and reassure
Lifestyle Changes: weight-bearing exercise healthy weight good calcium intake good vitamin D Avoiding falls Stop smoking Reduce alcohol
Med treatment:
bisphosphonates - alendronic acid:
- Decrease osteoclast activity - slows down bone resorption & bone turnover
- Side effects = reflux and oesophageal erosions, Atypical fractures (e.g. atypical femoral fractures), Osteonecrosis of the jaw, Osteonecrosis of the external auditory canal
- Should be taken on an empty stomach, sitting upright for 30 mins before moving or eating
- examples: alendronate, risedronate, zoledronic acid
Denosumab - monoclonal antibody to RANK ligand - inhibits osteoclasts
others: strontium ranelate, raloxifene
HRT - for women that go through the menopause early
wtf are seronegative spondyloarthropathies ? + common features (mnemonic)
Group of inflammatory diseases of the spine and sacroiliac joints.
Seronegative = there is NO rheumatoid factor
features: Sausage digits (dactylitis) Psoriasis Inflammatory back pain NSAIDS - good response Enthesitis (heel)
Arthritis
Crohn’s / UC / high CRP
HLA-B27
Eye - anterior uveitis / iritis
wtf is ankylosing spondylitis?
Chronic inflammatory disorder of spine (vertebral column) and sacroiliac joints
Inflammation causes pain and stiffness - can progress to fusion of joints aka bamboo spine
Inflammation heals with new bone formation - syndesmophytes
(90% of patients with AS have HLA B27 gene
2% of people with gene will get AS)
presentation of ankylosing spondylitis
young adult male (late teens/20s)
symp develop gradually across 3 months+
main presenting feature: lower back pain and stiffness, sacroiliac pain (buttock)
worse during rest (sleep - may wake patient up)
improves after 30 mins+ and during day as patient moves more
vertebral fractures are a key complication
ankylosing spondylitis associations?
Systemic symptoms eg. weight loss, fever and fatigue
Chest pain (costovertebral and costosternal joints)
Enthesitis - inflam where tendons or ligaments insert in to bone eg. plantar fasciitis and achilles tendonitis
Dactylitis inflam of finger or toe
Anaemia
Anterior uveitis (inflam of middle layer of eye)
Aortitis (inflam of aorta)
Heart block due to fibrosis of heart’s conductive system
Restrictive lung disease due to restricted chest wall movement
Pulmonary fibrosis at upper lobes of lungs (1% of AS patients)
Inflammatory bowel disease
investigate ankylosing spondylitis?
schober’s test - mobility of spine (find L5 vertebrae and measure distance 15cm up before and after person bends over, under 20cm indicates AS)
Inflam markers rise
HLA B27 test
xray of spine and sacrum - changes:
- Squaring of the vertebral bodies
- Subchondral sclerosis and erosions
- Syndesmophytes (areas of bone growth where ligaments insert into the bone)
- Ossification of the ligaments, discs and joints
- Fusion of the facet, sacroiliac and costovertebral joints
MRI of spine - may show bone marrow oedema (before any xray changes)
manage ankylosing spondylitis?
1st line - exercise and physio
2nd line - NSAIDs
3rd line - anti-TNF eg infliximab / etanercept
4th line - secukinumab - monoclonal antibody against interleukin-17
+ avoid smoking, bisphosphonates to treat osteoporosis, occasional surgery for deformities
wtf is psoriatic arthritis? + multiple patterns of disease
inflammatory arthritis associated with psoriasis
Occurs in 10-20% of pts with psoriasis
Multiple patterns of disease:
Symmetrical polyarthritis - similar to RA (hands, wrists, DIP joints)
Asymmetrical oligoarthritis (only affects a few joints/juvenile eg. fingers and toes)
DIPJ arthritis - dactylitis = characteristic
Spondylitic arthritis - similar to ankylosing spondylitis (eg. back stiffness, sacroilitis)
Arthritis mutilans - severe deformity where small bones in hands and feet are destroyed = progressive shortening of digit, skin folding aka ‘telescopic finger’
areas to look for hidden psoriasis? + other symptoms
behind/inside ear, scalp, umbilicus, genitals, nails (pitting/onycholysis - separation of the nail from the nail bed)
enthesitis
eye disease (conjunctivitis, anterior uveitis)
aortitis
amyloidosis (abnormal protein, amyloid, builds up in organs and interferes with normal function)
investigate and manage psoriatic arthritis?
Investigations:
PEST scoring tool
X-ray - erosive changes
“Pencil-in-cup” deformity
Management:
NSAIDs for pain
DMARDs - eg methotrexate / sulfasalazine
Anti-TNF drugs - eg infliximab
wtf is reactive arthritis? + causes
also known as reiter syndrome
synovitis occurs in joints as reaction to recent infective trigger = causes acute monoarthritis affecting single joint in lower limb eg. knee - warm/swollen/painful
unlike septic arthritis, there is no infection in joint
most common infections - gastroenteritis, chlamidya
gonorrhoea causes gonococcal septic arthritis
HLA B27 gene, seronegative spondyloarthropathy
